Gastrointestinal Surgery Practice Questions

Q: A wide mouth Meckel's diverticulum is found incidentally during laparotomy. What is the recommended treatment?

Leave as is. **Explanation:** The management of an incidentally discovered Meckel’s diverticulum (MD) remains a classic debate in surgery, but current consensus for NEET-PG follows the principle of **conservative management** for asymptomatic, wide-mouthed diverticula. **Why "Leave as is" is correct:** A **wide-mouthed** diverticulum is at very low risk for complications like diverticulitis or obstruction because intestinal contents can flow freely in and out, preventing stasis. In adults, the risk of developing complications from an asymptomatic MD is approximately 4–6%, whereas the risk of postoperative complications (adhesions, leak) from an unnecessary resection is often higher. Therefore, if the diverticulum is asymptomatic, wide-based, and feels soft (no palpable ectopic tissue), it should be left alone. **Why other options are incorrect:** * **A & C (Resection/Ligation):** Simple diverticulectomy or ligation is reserved for symptomatic cases (like diverticulitis) or high-risk incidental cases (narrow base, long length >2cm, or presence of palpable nodules). * **D (Resection with ileum):** Formal wedge resection or segmental ileal resection is mandatory only if there is **bleeding** (to ensure the ectopic gastric mucosa in the adjacent ileum is removed) or if the base is inflamed/gangrenous. **High-Yield Clinical Pearls for NEET-PG:** 1. **Rule of 2s:** 2% population, 2 inches long, 2 feet from ileocecal valve, 2% symptomatic, 2 types of ectopic tissue (Gastric > Pancreatic). 2. **Most common presentation:** Painless lower GI bleed in children; Intestinal obstruction in adults. 3. **Incidental Resection Criteria:** Resect if the patient is 2cm long, has a narrow neck, or feels thickened (suggesting ectopic mucosa). 4. **Technetium-99m Pertechnetate scan:** The investigation of choice for bleeding MD (detects ectopic gastric mucosa).

Q: Paralytic ileus is characterized by which of the following findings, except?

Loops of intestine are not seen due to loss of peristalsis. **Explanation:** Paralytic ileus is a state of functional intestinal obstruction where there is a failure of peristalsis without a mechanical blockage. **1. Why Option D is the Correct Answer (The Exception):** In paralytic ileus, the loops of the intestine are **clearly visible** on imaging (X-ray or CT). Because peristalsis has ceased, the bowel becomes distended with gas and fluid. These dilated, gas-filled loops are a hallmark radiological finding. The statement that "loops are not seen" is factually incorrect, making it the right choice for an "except" question. **2. Analysis of Incorrect Options:** * **Option A (No bowel sounds):** Since there is a global absence of peristaltic activity (aperistalsis), auscultation typically reveals a "silent abdomen." This is a classic clinical feature. * **Option B (No passage of flatus):** Because the functional movement of the gut has stopped, gas and feces cannot be propelled distally, leading to absolute constipation and failure to pass flatus. * **Option C (Gas-filled loops with fluid levels):** On an erect abdominal X-ray, paralytic ileus shows generalized dilatation of both the small and large bowel. Multiple air-fluid levels are seen at the same height in the same loop (unlike the "step-ladder" pattern of mechanical obstruction). **3. Clinical Pearls for NEET-PG:** * **Most common cause:** Post-operative state (Physiological ileus). Normal recovery: Small bowel (0–24h) > Stomach (24–48h) > Colon (48–72h). * **Electrolyte Imbalance:** Hypokalemia is the most common metabolic cause of paralytic ileus. * **Radiology:** Characterized by "Gas in the Rectum" (often absent in complete mechanical obstruction). * **Management:** Usually conservative (NPO, IV fluids, nasogastric decompression, and correction of electrolytes). Avoid opioids as they worsen the condition.

Q: A 50-year-old woman presented with bilateral solid ovarian tumors, ascites, and an ulcerative growth in the pyloric region of the stomach. What is the most likely diagnosis?

Gastric adenocarcinoma. ### Explanation The clinical presentation described is a classic case of **Krukenberg Tumor**, which refers to a metastatic signet-ring cell carcinoma of the ovary, most commonly originating from a primary site in the **stomach (Gastric Adenocarcinoma)**. **Why Gastric Adenocarcinoma is correct:** In this patient, the "ulcerative growth in the pyloric region" represents the primary malignancy. Krukenberg tumors are characterized by **bilateral, solid ovarian enlargement** resulting from retrograde lymphatic spread or transcoelomic seeding. While the colon, breast, and appendix can also be primary sites, the stomach is the most frequent source (approx. 70% of cases). The presence of ascites further suggests peritoneal dissemination. **Why the other options are incorrect:** * **Ovarian malignancy:** While the patient has ovarian tumors, the presence of a gastric pyloric mass indicates that the ovarian involvement is secondary (metastatic) rather than primary. * **Uterine malignancy:** Uterine cancers typically spread to pelvic lymph nodes or the lungs; they do not commonly present with a primary gastric mass and bilateral solid ovarian tumors. * **Duodenal adenocarcinoma:** This is significantly rarer than gastric cancer and is not the classic primary site associated with the eponymous Krukenberg tumor. **Clinical Pearls for NEET-PG:** * **Histology:** Look for **Signet-ring cells** (mucin-filled cytoplasm displacing the nucleus to the periphery). * **Route of spread:** Most commonly believed to be **retrograde lymphatic spread**, though transcoelomic seeding occurs. * **Sister Mary Joseph Nodule:** Another sign of gastric metastasis, presenting as a palpable nodule at the umbilicus. * **Virchow’s Node:** Left supraclavicular lymphadenopathy, often the first sign of hidden gastric malignancy.

Q: Which of the following is not an indication for splenectomy?

All of the above. **Explanation:** The correct answer is **D. All of the above**, as none of these conditions are absolute indications for splenectomy in the modern era of medical management. Splenectomy is typically reserved for cases that are refractory to medical therapy or present with specific complications. 1. **Immune Thrombocytopenic Purpura (ITP):** Splenectomy is no longer a first-line treatment. It is indicated only if the patient fails medical management (Corticosteroids, IVIG, or Rituximab) or has life-threatening bleeding. 2. **Beta Thalassemia:** Splenectomy is indicated only in cases of **Thalassemia Intermedia** or **Major** when there is massive splenomegaly causing mechanical discomfort, symptomatic hypersplenism (worsening anemia/leukopenia), or when transfusion requirements exceed 200-250 ml/kg/year. 3. **Sickle Cell Disease:** Splenectomy is rarely indicated because most patients undergo **"autosplenectomy"** (splenic infarction) by childhood. It is only considered in specific emergencies like **Splenic Sequestration Crisis** or a splenic abscess. **Clinical Pearls for NEET-PG:** * **Most common indication for elective splenectomy:** ITP. * **Most common indication for emergency splenectomy:** Trauma (Splenic rupture). * **Vaccination Protocol:** To prevent **OPSI (Overwhelming Post-Splenectomy Infection)**, patients must be vaccinated against *H. influenzae*, *N. meningitidis*, and *S. pneumoniae* at least **2 weeks before** elective surgery or **2 weeks after** emergency surgery. * **Peripheral Smear Findings:** Look for **Howell-Jolly bodies**, Pappenheimer bodies, and Heinz bodies post-splenectomy.

Q: Which is the most common cause of the below condition?

Gastric carcinoma. ***Gastric carcinoma*** - **Antral carcinoma** is the most common cause of **gastric outlet obstruction** in adults, causing pyloric stenosis through tumor growth and fibrosis. - Typically presents with **progressive dysphagia**, **weight loss**, and **epigastric pain** with a palpable mass. *Gastric ulcer* - Gastric ulcers rarely cause **pyloric stenosis** as they typically occur in the body or fundus, not near the pylorus. - When they do occur near the pylorus, they more commonly cause **perforation** or **bleeding** rather than obstruction. *Duodenal ulcer* - Can cause **pyloroduodenal obstruction** through scarring and fibrosis, but is **less common** than gastric carcinoma as a cause of gastric outlet obstruction. - Usually associated with **H. pylori infection** and presents with **postprandial pain** rather than progressive obstruction. *Hiatus hernia* - Involves **herniation of stomach** through the **diaphragmatic hiatus** into the thoracic cavity. - Does **not cause pyloric stenosis** as it affects the gastroesophageal junction, not the gastric outlet.

Q: A patient with a gastric ulcer has a biopsy that reveals malignancy. What is the next step in management?

CT abdomen. **Explanation:** Once a gastric ulcer is histologically confirmed as malignant (Gastric Adenocarcinoma), the immediate next step is **clinical staging** to determine the extent of the disease and assess resectability. **Why CT Abdomen is the correct answer:** Contrast-Enhanced Computed Tomography (CECT) of the abdomen and pelvis is the **standard initial staging investigation** for gastric cancer. It is highly effective at evaluating the local extent of the tumor (T stage), identifying regional lymphadenopathy (N stage), and detecting distant visceral metastases (M stage), particularly to the liver. **Analysis of Incorrect Options:** * **A. Ultrasound abdomen:** While useful for screening, USG lacks the sensitivity and specificity required for accurate TNM staging of gastric cancer and cannot reliably assess nodal involvement or depth of wall invasion. * **C. CA 19-9 level:** Tumor markers (CEA, CA 19-9) are not used for the initial diagnosis or staging of gastric cancer. They are primarily used for monitoring recurrence post-treatment. * **D. Laparoscopy:** Diagnostic laparoscopy (with peritoneal washings) is the most sensitive method for detecting occult peritoneal carcinomatosis. However, it is performed **after** a CT scan has ruled out distant hematogenous metastasis, making it a subsequent step rather than the immediate next step. **NEET-PG High-Yield Pearls:** * **Investigation of Choice (IOC) for Diagnosis:** Upper GI Endoscopy + Biopsy (minimum 6-8 biopsies from the ulcer edge). * **IOC for Staging:** CECT Abdomen and Pelvis. * **Most accurate for T and N staging:** Endoscopic Ultrasound (EUS). * **Most sensitive for peritoneal metastasis:** Diagnostic Laparoscopy. * **Virchow’s Node:** Left supraclavicular lymph node involvement (Troisier’s sign).

Question 1

A wide mouth Meckel's diverticulum is found incidentally during laparotomy. What is the recommended treatment?

Accepted Answer

Leave as is

Answer

Resection of the diverticulum

Answer

Ligate at the base

Answer

Resection with a portion of the ileum

Question 2

Paralytic ileus is characterized by which of the following findings, except?

Accepted Answer

Loops of intestine are not seen due to loss of peristalsis

Answer

No bowel sounds on auscultation

Answer

No passage of flatus

Answer

Gas-filled loops of intestine with multiple fluid levels

Question 3

Which of the following features characterize acute intestinal obstruction?

Accepted Answer

In colonic obstruction, distension is more common than vomiting.

Answer

Vomiting is common in duodenal obstruction.

Answer

Pain after each attack of vomiting is characteristic of ileal obstruction.

Answer

Colicky pain changing to steady pain indicates strangulation.

Question 4

A 50-year-old woman presented with bilateral solid ovarian tumors, ascites, and an ulcerative growth in the pyloric region of the stomach. What is the most likely diagnosis?

Accepted Answer

Gastric adenocarcinoma

Answer

Ovarian malignancy

Answer

Uterine malignancy

Answer

Duodenal adenocarcinoma

Question 5

What is the treatment of choice for perforation of the cervical esophagus?

Accepted Answer

Cervical exploration and drainage of the superior mediastinum, along with the use of antibiotics

Answer

Bed rest and use of antibiotics

Answer

Nasogastric intubation and use of antibiotics

Answer

Resection and colonic interposition

Question 6

A 60-year-old male is diagnosed with carcinoma of the stomach. A CT scan of the abdomen reveals a 4x4 cm mass in the antrum with involvement of celiac and right gastric nodes. What is the management of choice?

Accepted Answer

Subtotal gastrectomy

Answer

Total gastrectomy

Answer

Palliative care

Answer

Chemotherapy

Question 7

Which of the following statements is NOT true regarding gastrointestinal tuberculosis?

Accepted Answer

Surgical management is the treatment of choice

Answer

Formation of transverse ulcers

Answer

Common site is the ileocecal region

Answer

An obtuse ileocecal angle is seen

Question 8

Which of the following is not an indication for splenectomy?

Accepted Answer

All of the above

Answer

Immune thrombocytopenic purpura (ITP)

Answer

Beta thalassemia

Answer

Sickle cell disease

Question 9

Which is the most common cause of the below condition?

Accepted Answer

Gastric carcinoma

Answer

Gastric ulcer

Answer

Duodenal ulcer

Answer

Hiatus hernia

Question 10

A patient with a gastric ulcer has a biopsy that reveals malignancy. What is the next step in management?

Accepted Answer

CT abdomen

Answer

Ultrasound abdomen

Answer

CA 19-9 level

Answer

Laparoscopy

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

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